Observations on a Set of Greco-Roman Eye, Ear, Nose, and Throat Surgical Instruments

Transcription

1 The Laryngoscope VC 2016 The American Laryngological, Rhinological and Otological Society, Inc. Contemporary Review Observations on a Set of Greco-Roman Eye, Ear, Nose, and Throat Surgical Instruments Herbert H. Dedo, MD The tools described in this article are verified to be Greco-Roman medical and surgical instruments for the eye, ear, nose, and throat. They include three myrtle leaf shaped scalpels, three ear spoons, a Q-tip, a forceps, a needle, and two arrow-pointed scalpels. One of the arrow-pointed scalpels is nearly identical to a Juerger keratome, suggesting that in Roman times, cataracts were extracted, not just couched into the posterior chamber. The description presented here goes beyond traditional archeological claims, because as a head and neck surgeon, I evaluated these instruments from a surgeon s point of view. For example, nonsurgeon medical historians have claimed the myrtle leaf shaped items were used as handles or for blunt dissection, which I feel is mistaken. Review of the literature reveals the Greco-Roman surgeons were doing tonsillectomies, tracheotomies, and cataract extractions, and recognized that swimming in dirty water could cause ear infection. However, it is clear that with poor or no anesthesia, the pain from blunt dissection would have been intolerable, and unnecessary tissue planes would have been opened increasing wound infection risks. Therefore, there would have been no need for the myrtle leaf shaped blade if it were just a handle. Key Words: Greco-Roman, eye, ear, nose, and throat surgical instruments. Laryngoscope, 127: , 2017 INTRODUCTION In August 1965, I purchased 21 bronze objects at an antiquities shop in the Grand Bazaar in Istanbul. I was told they were found in a grave near Izmir (Roman Smyrna), where Hicesis led a medical center. 1 Six are identical to ones in the National Museum of Naples found at Pompeii, 2 the British Museum, and the Burroughs Welcome Museum in London. In 1967, Professor Burhan Tezcan, then Chairman of the Department of Archeology at the University of Ankara, Turkey, confirmed their authenticity and stated he would prefer to have a modern surgeon rather than an archeologist or a historian evaluate these items to establish their functions. Manuscripts are extremely scarce for the Roman period. Roman medical writers were encyclopedists, with some also being self-trained physicians, such as Celsus. 3 Galen, 4 however, was a treating doctor. If a special surgical instrument is found, it is likely that it has been used for the task for which it was specially designed. Thus, the instruments described here may provide interesting information about the surgical practices of the Roman period. From the Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, U.S.A. Editor s Note: This Manuscript was accepted for publication July 19, The author has no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Professor Emeritus, Herbert H. Dedo, MD, 1802 Floribunda Avenue, Hillsborough, CA hhdedo@ gmail.com DOI: /lary Scalpels Three of the 21 objects are, in my opinion, bronze scalpel handles (labe in Greek meaning handle) and blades (called smile in Greek and scalpellus in Latin) (L. J. Bliquez, personal communication, September 10, 2009). 4 One is small and two are large. One of the large pairs is shown in Figure 1A and 1D. The myrtle leaf shaped blade is admirably designed for cutting skin and muscle with a curve, like a modern scalpel blade (Fig. 1C). The different sizes suggest that they were used in different anatomical areas. For example, Paulus Aegineta ( AD) 5 describes the tracheotomy technique used by Antyllus (2nd century AD), when infection of the tongue, tonsils, mouth, and palate caused swollen tissue to obstruct the airway. He describes cutting between the strap muscles in the lower anterior neck, and then incising the tracheal membrane between two rings so the air could be heard moving in and out. The larger scalpels (Fig. 1A,D) would be able to make the incision in the skin and to the trachea, and the smaller one would be more appropriate for making a small opening in the trachea between the rings to prevent later stenosis. 5 The smaller one would also have worked well for performing a tonsillectomy, which is well described by Paulus Aeginata. 5 These ancient blades are double-edged, whereas a modern scalpel has one cutting edge. With three such blades in a kit, a surgeon could have performed most or all of an operation before needing to have the blades resharpened. 354

2 Fig. 1. The illustrations show how similar some of these bronze surgical instruments are to the steel modern ones. (A and D) Greco-Roman myrtle leaf scalpel blade and handle. (B) Modern (1890s) handle. (C) Modern (1890s) single-edge scalpel blade with curve similar to (A). (D) Side view of (A). dangerous if it were sharp, as I illustrate in Figure 2A. Many surgeons today hold the scalpel handle with the thumb on one side, opposed by the tips of three or four fingers as shown in Figure 2B, which is known as the surgeon s grip. This grip would have avoided the sharp edges at both ends. Using the surgeon s grip, the myrtle leaf shaped blade would have had an excellent curved shape for skin incisions and for sharp, not blunt, dissection of the deeper tissues. Rapid and sharp-cutting dissection, rather than blunt-pushing dissection, is faster, more precise, does not open up unnecessary tissue planes that would spread infection, and is less painful when operating without good general anesthesia. The curve of the myrtle leaf shaped scalpel is still used in Europe and the United States as a blade when delicate incision, sharp dissection, and the drainage of abscesses or opening of fistulas are necessary. This shows its basic importance in surgery. The instrument in Figure 3A (Roman, valsell, a small forceps or tweezers), when found with cosmetic tools, is called tweezers, and with surgical sets are called forceps and are used by doctors to grasp tissues or to remove foreign bodies from the ear. 5 The owner(s) of this set of instruments possibly did eye surgery, as suggested The corroded remains of the steel blade in the locking groove in the other end of these bronze square handles and scalpel blades are visible. Close examination suggests that they were attached by means of a very ingenious and well-made tapering groove, like the modern handle end blade (Fig. 1B,C), with a wider round hole at the end (Fig. 1D). According to Bliquez, 2 Milne, 6 Tabanelli, 7 and Thompson, 8 the bronze portion of these instruments was a spatula handle for blunt dissection, whereas the steel blade at the other end was used for sharp dissection. Milne quotes a Galen 4 reference to a scalpel with a bronze handle and a steel blade. However, Galen 4 does not state that the myrtle leaf shaped end is not for cutting. Regarding the Greco-Roman surgical instrument collection at John Hopkins Medical Center, Buckler and Caton 9 believe it is possible that the Greeks and Romans had superstitions about cutting with bronze knives instead of steel. They suggest that the initial skin incision may have been made with the bronze scalpel, and further cutting may have been done with the steel blade at the other end of the square bronze handle. They also note that the edges of the myrtle leaf shaped ends can be quite sharp. This supports the idea that the bronze blades were used for sharp-cutting dissection, not blunt cutting, and that it is not just part of the handle, as argued by many authors. Roman stone sculpture representations, like the one on the temple wall at Kom Ombo in Egypt, show how the steel end could have looked before it had rusted away. In that case, the steel blade was full bellied and curved like the breast of a woman. 9 From my surgical experience, the myrtle leaf end on the square bronze handle would be awkward and Fig. 2. (A) Scalpel held like a pencil to cut with the missing steel blade so the bronze blade is cutting the web between the surgeon s thumb and index finger. (B) Surgeon s grip on square handle to use the myrtle leaf blade [Color figure can be viewed in the online issue, which is available at 355

3 Fig. 3. Forceps and eye surgery instruments. (A) Forceps. (B) Needle for cataract couching. (C) Small arrow head tipped scalpel. (D) Arrow head tipped scalpel, possibly a keratome. (E) modern Juerger keratome. by the presence of the 8.5-cm long needle with four rings on one end (Fig. 3B). This is not a suture needle, as it has no hole for a suture. The enlargement on the blunt end would have made it easy to grasp. This needle has the usual size and shape of a couching needle used for putting to bed a cataract. Elliott, 10 Celsus, 3 Paulus Aegineta, 5 and the Sushruta books (5th century BC, India) 11 describe this in detail. It involved pushing the cloudy lens back and down into the vitreous in the posterior compartment of the eye with a special needle, short enough to be concealed preoperatively in the cupped hand of the surgeon. The Sushruta books 11 show that cataract couching was performed in India by the 5th century BCE. Couching of the lens was still being done in some parts of India as late as 1917, when the practice was observed and described by Dr. Robert Elliott. 10 The small bronze spear-pointed probe or knife (Fig. 3C) may be a bronze example of the fine (iron) needle flattened, like a spear point (Roman, tenuis acts ferrera, Celsus 3 ). These instruments were heated in fire and used to cauterize eyelids that had turned inward against the eyeball so the eyelashes scratched the cornea. Celsus 3 also indicates it was used for loosening and removing nasal polyps from the bone. The fourth instrument (Fig. 3D) resembles a modern keratome (Juerger model from the 1960s) (Fig. 3E), which was used in cataract surgery to make the cut at the edge of the cornea through which the cloudy white lens was removed. In fact, the angle of the two cutting edges at the point, the thin flat blade, its width at the widest point, and the blade handle angle are all nearly identical. Only one Roman surgeon, Antyllus (2nd century AD), is credited by Paulus Aegineta 5 with the removal of cataracts by extraction (sometimes by suction), instead of just couching the lens. According to Kirby, 12 the Arab surgeons Avicenna and Rhazes were also aware that cataracts were removed and not just couched in the Roman period. 356 There has been considerable controversy over whether cataracts were actually being extracted from the eye during the Roman period. Jacques Deviel ( ) is usually credited with originating the treatment of cataract by extraction in modern times. 13 However, if it is accepted that Figure 3D is a cataract-incision keratome, then it provides confirmation of Paulus Aegineta s statement that extractions were being done during the Roman period. 5 Figure 4A shows a probe with spiral grooves on the enlarged pointed tip used to make a cotton applicator (i.e., a Roman cotton Q-Tip). Celsus 3 and Paulus Aegineta 5 describe using the ear probe (specillum oraculario) wrapped in cotton to wipe discharge from an infected ear when it had gotten foul water in it. With larger quantities of drainage, they advised sucking the discharge out with a reed held in the doctor s mouth! Celsus 3 and Galen 4 also described soaking the cottonwrapped specillum oraculario in sticky resin and using it to remove foreign bodies, such as fleas from the ear canal. Figure 4B is a combination short ear curette with an angulated cup on one end (for removing earwax, cerumen, or foreign bodies) and a toothpick on the other end. Ear spoons, scoops, or curettes (Fig. 4B D) (Roman, specillum oraculario) were used for removing earwax (sordes) or maggots if near the surface. 3 As compared to a modern example (eg, Figure 4E) these are similar in size and have an identical angle at the junction of the scoop and handle (Fig. 4E). Although Celsus 3 and others often refer to this instrument, Milne 6 says typical specimens are now uncommon. However, the example shown in his illustration may be mislabeled, because it is too large to fit in the ear and pass behind the earwax to remove it. However, the examples in my collection fit easily into the ear canal. Three ear curettes were found in this set (Fig. 4B D). They worked well to remove cerumen. Galen 4 indicates the specillum oraculario was sharply pointed on the opposite end, such as these are, without an olivary enlargement. The pointed end was used for instilling Fig. 4. Ear Instruments. (A) Pointed and grooved applicator. (B) Ear curette and tooth pick. (C, D) Ear curettes. (E) Contemporary ear curette. (F) Eyelash rasp or ear curette. (G) Foreign body remover.

4 eardrops. A ball of cotton saturated with a wine and vinegar solution was wrapped around the middle of the instrument. When squeezed with the pointed end in the ear opening, the liquid ran down into the ear. 5 One percent boric acid in 80% ethyl alcohol is still occasionally more effective with ear canal infections then antibiotic ear drops. The instrument shown in Figure 4F, with a serrated edge, may be an example of a specillum asperatum 3 or blepharoxyston 5 (translated from Greek as sharp instrument for the eyelid ). This was a rasp that could be used for scraping away the crusts of eye infections. 5 The reverse side was said to be shaped like a seashell, as this one is. (The example proposed by Milne 6 clearly is much too large to be used as an eye instrument.) Paulus Aegineta describes two techniques for removing sordes (cerumen) from ears. 5 He says that warm oil may be injected into the ear (to soften it), followed by a syringing with tepid water (with the oriculario clystere). If the object is a pea or bean (which will swell if moistened), he advises it should be removed with an ear curette (specillum oraculario) or hook (tenaculum). 5 This is still good advice. The instrument in Figure 4G is possibly a modified ear scoop (specillum vulnerarium), used for removing foreign bodies from skin wounds, such as stones and other missiles launched from slings. 5 The scoop on the end was described as the same size and angle as that of the ear scoop. However, the adjacent handle has been thickened in such a way that it would be much stronger than necessary for an ear curette. Figure 4G is the only instrument with a shiny, smooth, green patina, unlike the rest, which have the dull, brown, rough surface, typical of Greco-Roman medical instruments. This shiny green patina is found on instruments in the British Museum, which is believed to be found on the facsimiles or copies made from casts of Roman instruments from Pompeii. The British Museum has a book written in 1906 that shows such copies for sale. The flexible probe seen in Figure 5A (Greek, dipyrene) 5 was used to determine the depth and direction of fistulae 5 and puncture wounds, 3 just as modern ones are used. The spatula (Fig. 5B) has a pointed narrow spoon on one end, with an olivary swelling on the other (Roman, cyanthiscomele). The bulbous end could have been used to probe a fistula, puncture wound, or urethral stricture. If necessary, the pointed grooved spatula end could have then been inserted into this tube to cut a stricture. Milne refers to this special type of cup-shaped probe as a cyanthiscomele, toseparateitfromthespathomele, with the flat spatula end. 6 The latter also could have been used to write on wax tablets and to erase mistakes. Figure 5C shows a probe of uncertain function. The squared box tip with an X incised on the end is distinctive, but I have been unable to locate any references to such a square end, as opposed to a round olivary enlargement. One can speculate it may have been used to fasten the end of a bandage, or to hold two pieces of clothing together. The suture needle (Fig. 5D) (Roman, sutura) 3 Fig. 5. Assorted instruments. (A) Double-tipped fistula probe. (B) Olivary tip at one end, pointed concave spatula at the other end. (C) Pointed probe with box-like handle. (D) Suture needle. (E) Spoon. resembles the bone needles used during the Paleolithic period to sew animal skins or to close wounds. The spoon (Fig. 5E) is identical to one in the late 19th century surgeon s set in the University of California, San Francisco Medical Museum, dating from the late 19th century. It was used for curetting and evacuating the hard core from a large abscess or boil. CONCLUSION The set of bronze Greco-Roman medical and surgical instruments described above consists of what I consider eye, ear, nose, and throat surgical instruments. The most important conclusion is about the instrument I believe is a keratome for extracting (not couching) a cataract. If this instrument is indeed a keratome, this provides the first modern proof that cataracts were extracted, as ascribed to Antyllus by Paulus Aegineta, 5 not merely couched, during the Roman period. It has been generally thought that cataract extraction only began in the 18th century with Jacques Deviel. 13 My other major difference with prior modern authors is that the myrtle leaf shaped end on the bronze handle was used for incisions and for sharp, not blunt, dissection. The use of some of these instruments was, in my opinion, misunderstood by previous students of Roman surgical instruments, who generally have been historians or archeologists and not surgeons. Lastly, Greco-Roman physicians and surgeons were more advanced in theory and technique than was taught in my formal training. Acknowledgments The author expresses his deep gratitude to the following individuals who assisted him in typing, writing, editing, discussing, and correcting this article. They are listed in alphabetical order and include Mr. Matthew Blanco, Mrs. Lori Griffie, Dr. Krzysztof Izdebski, Ms. Amy M. Matson, Ms. Carol Shoaff, and Mrs. Winifred Wong. 357

5 BIBLIOGRAPHY 1. Scarborough J. Roman Medicine. Ithaca, NY: Cornell University Press; Bliquez LJ, Jackson R. Roman Surgical Instruments and Other Minor Objects in the National Archaeological Museum of Naples. Mainz, Germany: Verlag Philipp von Zabern; Celsus AC. Celsus de Medicina. Spencer WG, trans-ed. London, United Kingdom: The Loeb Classical Library; Galen. Galen on the Usefulness of the Parts of the Body. Helmreich G, ed. May MT, trans. Ithaca, NY: Cornell University Press; Aegineta P. The Seven Books of Paulus Aegineta. Vol. 6. Adams F, trans. London, United Kingdom: Sydenham Society; Milne J. Surgical Instruments in Greek and Roman Times. Oxford, United Kingdom: Clarendon Press; Tabanelli M. Lo Strumento Chirurgico e la Sua Storia. Forli, Italy: Romagna Medica; Thompson CJS. The History and Evolution of Surgical Instruments. New York, NY: Schuman s; Buckler WH, Caton R. Account of a group of medical and surgical instruments found at Kolophon. Proc R Soc Med 1914;7(Sect Hist Med): Elliot RH. The Indian Operation of Couching for Cataract. London, United Kingdom: H.K. Lewis; Sushruta. The Sushruta Samhita, Vol. 2. 2nd ed. Varanasi, India: Chowkhamba Sanskrit Series Office; Kirby AM, Daniel B. The Surgery of Cataract. Philadelphia, PA: J.B. Lippincott; Garrison FH. An Introduction to the History of Medicine. 4th ed. Philadelphia, PA: W.B. Saunders;